“5.12”汶川大地震伤员挤压综合征的早期诊治
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摘要
目的总结汶川大地震后挤压综合征的早期诊断和以外科治疗为主、多科协作下的综合治疗要点及其临床价值。方法66例挤压综合征患者中,行截肢或关节离断手术22例,行骨筋膜室切开减压38例,因感染或肢体坏死行二次截肢6例;所有患者均予以补液、输血、扩创换药、扩创缝合创面、抗感染、利尿或血液透析、全身支持及并存病的治疗。结果截肢或关节离断术后创面一期愈合11例,二期扩创缝合6例;筋膜切开减压创面直接缝合14例,游离植皮11例,二期扩创缝合10例;术后感染32例,有8例创面尚未愈合;49例合并急性肾功能衰竭患者中,37例经血液透析肾功能好转并停止透析,继续透析治疗12例,其中4例患者肾功能改善不明显,13例肾功能不全者经补液、利尿、碱化尿液等治疗好转,无1例进展为急性肾功能衰竭,全组无1例死亡。结论挤压综合征的早期诊断要点是挤压史、受压肢体的症状、体征及实验室检查;早期治疗挤压综合征的关键是补液、纠正低血容量和高钾血症、适时切开筋膜减压或截肢;术后积极有效的创面处理、血液透析、合并症处理和全身营养支持等多科协作下的综合治疗是成功治疗挤压综合征的保障。
[Objective] To summarize the main points of early diagnosis of crush syndrome originated from Wenchuan megaseism and the comprehensive treatment with characteristic of surgical therapy combined with multi-department cooperation and its clinical value.[Methods] 22 of 66 patients with crush syndrome underwent amputation or exarticulation,38 osteofascial compartment open decompression and 6 re-amputation due to infection or limbs necrosis.All the 66 patients received fluid infusion,blood transfusion,enlarged debridement and change dressings,enlarged debridement and suture,anti-infection,diuresis or haemodialysis,systemic supportive treatment and management of comorbidities.[Results] Primary healing after amputation or exarticulation occurred in 11 patients,secondary enlarged debridement and suture in 6,aponeurosis open decompression and direct suture of raw surface in 14,dissociation dermatoplasty in 11 and secondary enlarged debridement and suture in 10.Postoperative infection existed in 32 cases and raw surface disunion in 8 cases.In 37 of 49 patients complicated with acute renal failure(ARF) who received haemodialysis,renal function improved and haemodialysis ceased.Continuative haemodialysis was performed in 12 cases and no significant renal function improvement existed in 4.Renal function improvement was obtained in 13 patients with renal inadequacy by means of fluid infusion,diuresis and urine basification.No acute renal failure occurred.No mortality existed in 66 patients.[Conclusions] The main points of early diagnosis of crush syndrome include crushing history,symptoms and objective signs of the compressed limbs,laboratory examination.The key points of early treating crush syndrome are fluid infusion,correcting hypovolemia and hyperkalemia,prompt osteofascial compartment open decompression or amputation.The combined therapy on the basis of multi-speciality cooperation,which includes active postoperative raw surface management,haemodialysis,complication management and systemic nutritional support may ensure treating crush syndrome successfully.
[Objective] To summarize the main points of early diagnosis of crush syndrome originated from Wenchuan megaseism and the comprehensive treatment with characteristic of surgical therapy combined with multi-department cooperation and its clinical value.[Methods] 22 of 66 patients with crush syndrome underwent amputation or exarticulation,38 osteofascial compartment open decompression and 6 re-amputation due to infection or limbs necrosis.All the 66 patients received fluid infusion,blood transfusion,enlarged debridement and change dressings,enlarged debridement and suture,anti-infection,diuresis or haemodialysis,systemic supportive treatment and management of comorbidities.[Results] Primary healing after amputation or exarticulation occurred in 11 patients,secondary enlarged debridement and suture in 6,aponeurosis open decompression and direct suture of raw surface in 14,dissociation dermatoplasty in 11 and secondary enlarged debridement and suture in 10.Postoperative infection existed in 32 cases and raw surface disunion in 8 cases.In 37 of 49 patients complicated with acute renal failure(ARF) who received haemodialysis,renal function improved and haemodialysis ceased.Continuative haemodialysis was performed in 12 cases and no significant renal function improvement existed in 4.Renal function improvement was obtained in 13 patients with renal inadequacy by means of fluid infusion,diuresis and urine basification.No acute renal failure occurred.No mortality existed in 66 patients.[Conclusions] The main points of early diagnosis of crush syndrome include crushing history,symptoms and objective signs of the compressed limbs,laboratory examination.The key points of early treating crush syndrome are fluid infusion,correcting hypovolemia and hyperkalemia,prompt osteofascial compartment open decompression or amputation.The combined therapy on the basis of multi-speciality cooperation,which includes active postoperative raw surface management,haemodialysis,complication management and systemic nutritional support may ensure treating crush syndrome successfully.
引文
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[5]BETTER OS,STEIN JH.Early management of shock and pro-phylaxis of acute renal failure in traumatic rhabdomyolysis[J].N Eng J Med,1990,322:825-829.
[6]吴柱国,莫湛宇,余权星.血液透析治疗小儿急性肾功能衰竭的临床研究[J].中国现代医学杂志,2002,l2(22):49-50.[6]WU ZG,MO ZY,YU QX.Clinical research of haemodialysis in treating acute renal failure in children[J].China Journal of Mod-ern Medicine,2002,l2(22):49-50.Chinese
[7]李远明,叶启发,伍锟,等.肾移植术后多尿性高钾诊治的临床研究[J].中国现代医学杂志,2008,18(9):1299-1300.[7]LI YM,YE QF,WU K,et al.Clinical research of the diagnosis and treatment for hydruric hyperkalemia after renal transplanta-tion[J].China Journal of Modern Medicine,2008,18(9):1299-1300.Chinese
[8]HUSSAIN A,KWAK HC,PALLISTER I.Crush syndrome:A comprehensive surgical strategy improves outcome[J].Injury,2006,12:53.
[9]SHEMAZU T,YOSHIOKA T,NAKATA Y,et al.Fluid resusci-tation and system complications in crush syndrome:14Han-shin-Awaji earthquake patients[J].J Trauma,1997,42:641-646.
[10]SIMTH J,GREAVES I.Crush injury and crush sundrome:A review[J].J Trauma,2003,54:s226-230.
[11]RAN D,TAITELMAN U,MICHAELSON M,et al.Prevention acute renal failure in traumatic rhabdomyalysis[J].Arch Intern Med,1984,144:277-280.
[2]DARIO G.Crush syndrome[J].Crit Care Med,2005,33:s34-41.
[3]DEMIRKIRAN O,DIKMEN Y,UTKU T,et al.Crush syndrome patients after the Marmara earthquake[J].Emerg Med J,2003,20:247-250.
[4]PEPE E,MOSESSO VN,FALK JL.Prehosipital fluid resuscita-tion of the patient with major trauma[J].Prehosp Emerg Care,2002,6:81-91.
[5]BETTER OS,STEIN JH.Early management of shock and pro-phylaxis of acute renal failure in traumatic rhabdomyolysis[J].N Eng J Med,1990,322:825-829.
[6]吴柱国,莫湛宇,余权星.血液透析治疗小儿急性肾功能衰竭的临床研究[J].中国现代医学杂志,2002,l2(22):49-50.[6]WU ZG,MO ZY,YU QX.Clinical research of haemodialysis in treating acute renal failure in children[J].China Journal of Mod-ern Medicine,2002,l2(22):49-50.Chinese
[7]李远明,叶启发,伍锟,等.肾移植术后多尿性高钾诊治的临床研究[J].中国现代医学杂志,2008,18(9):1299-1300.[7]LI YM,YE QF,WU K,et al.Clinical research of the diagnosis and treatment for hydruric hyperkalemia after renal transplanta-tion[J].China Journal of Modern Medicine,2008,18(9):1299-1300.Chinese
[8]HUSSAIN A,KWAK HC,PALLISTER I.Crush syndrome:A comprehensive surgical strategy improves outcome[J].Injury,2006,12:53.
[9]SHEMAZU T,YOSHIOKA T,NAKATA Y,et al.Fluid resusci-tation and system complications in crush syndrome:14Han-shin-Awaji earthquake patients[J].J Trauma,1997,42:641-646.
[10]SIMTH J,GREAVES I.Crush injury and crush sundrome:A review[J].J Trauma,2003,54:s226-230.
[11]RAN D,TAITELMAN U,MICHAELSON M,et al.Prevention acute renal failure in traumatic rhabdomyalysis[J].Arch Intern Med,1984,144:277-280.
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